Obstruction of the lacrimal drainage system

An Unusual Case: Nasolacrimal Stent Penetrating the Oral Cavity

Lacrimal bypass tubes create a fistula from the conjunctiva to the lacrimal sac or the nasal cavity. Fluoroscopic nonoperative placement of a plastic stent has shown successful results in the treatment of epiphora. Polyurethane lacrimal stents have been reported as a safe, easy, non-surgical treatment in the treatment of distal lacrimal obstruction. Recurrence due to stent occlusion of the granulation tissue is common. Stent displacement is very rare. We presented the first case of the stent protruded into the mouth in the literature.

Ostium Characteristics and Its Relevance in Successful Outcome Following Endoscopic Dacryocystorhinostomy

Study aims to assess the postoperative ostium shrinkage pattern and also attempted to evaluate various ostium parameters and their impact on surgical outcome by using DOS scoring system. Prospective study comprising 44 patients of NLD obstruction with 52 procedures performed during October 2016 to November 2018. Various dimensions of bony neo-ostium were recorded intraoperatively and during 1st, 3rd and 6th month follow up. Degree of ostium shrinkage and its correlation with anatomical and functional success was studied. DCR ostium (DOS) scoring system, comprised of ten various ostium parameters, was used to evaluate postoperative ostium. Intraoperative mean ostium height and width were 13.67 ± 2.76 mm and 7.0 ± 1.94 mm and surface area was 98.33 ± 38.46 mm2. Maximum ostium shrinkage (by 66.93%) occurred at 1 month and after which, average size of ostium was quite stable with little change. The anatomical and functional success rate was 94.23% and failure rate was 5.77%. DOS score was "excellent" in 40(75.92%), "good" in 9(17.31%) and "poor" in 3(5.77%) cases. Meticulous evaluation at regular intervals is important for surgeon to understand the characters of ostium during healing and also helps in early detection of pathologies and may facilitate early corrective intervention. We believe that DOS system provides an effective protocol to standardize the ostium evaluation. The ostium parameters with favourable surgical outcome are ostium location anterior to axilla of MT, circular/ oval shape with shallow base, size > 8 × 5 mm, clearly visualized and dynamic ICO, absence of ostium cicatrization, granulomas, synechiae and other pathologies.

Treatment for functional epiphora with botulinum toxin-A versus lateral tarsal strip in a randomized trial

INTRODUCTION

To compare the efficacy of botulinum toxin A (BoNTA) injection into the lacrimal gland versus lateral tarsal strip (LTS) for functional epiphora.

METHODS

Randomized clinical trial. Sequential, parallel, non-blinded study design. Patients aged 18 years or older with functional epiphora and a minimum score of 3 in Munk Scale (MS) were randomized to BoNTA or LTS group. Changes in Munk scale, Schirmer test (ST) and quality of life (QoL) were assessed at week 6 and during follow-up until week 30. The mean time without epiphora and the adverse events (AE) were recorded.

RESULTS

The final analysis included 25 patients, 12 (21 eyes) assigned to BoNTA (5U/0.05 mL) and 13 (20 eyes) to LTS. At 6 weeks there was an improvement in the MS in BoNTA versus LTS group (-2.48 vs -1.55, P = .0152) and at 12 weeks (-2.68 vs -1.69, P = .0267). A significant decrease was noted in the ST at week 2, 12 and 30 with BoNTA. The QoL improved after both interventions without statistical significance. The mean duration of effectiveness in BoNTA group was 26.2 weeks (range 7.7-36.6) and in LTS group was 24.8 weeks (range 6.7-37.6), P = .937. The main AE were temporary eyelid ptosis in 25% (3/12) of the BoNTA group and surgical scar discomfort in 23% (3/13) of the LTS groups, P = .722. No AE were classified as severe.

CONCLUSION

BoNTA injection into the lacrimal gland is a safe and effective treatment for functional epiphora, with a greater decrease in MS at 6 and 12 weeks compared with LTS.

Comparison of the efficacies of 1.0 and 1.5 mm silicone tubes for the treatment of nasolacrimal duct obstruction

This retrospective observational study analyzed the postoperative outcomes of bicanalicular intubation using different diameters of tube stents for treating postsaccal nasolacrimal duct obstruction. A total of 130 patients diagnosed with postsaccal obstruction who underwent endoscopic-assisted silicone tube intubation were included in the study. Patients intubated with a 1.5-mm large-diameter tube were designated as the LD group, and those with a 1.0-mm normal-diameter tube were designated as the ND group. The patency rates of the two groups at 1 year after tube removal were compared using the Kaplan–Meier curve and restricted mean survival time (RMST) method with τ = 365 days. Results demonstrated that the recurrence rate after tube removal was significantly lower in the LD group as compared with the ND group (p = 0.001). The patency rates at 1 year after removal in the LD and ND group were 85.7% (95% confidence interval [CI]: 75.4, 91.9) and 73.9% (95% CI: 61.7, 82.8), respectively. When comparing the patency rates by the RMST method at τ = 365 days, the RMST difference, RMST ratio, and RMTL ratio were higher in the LD group at p = 0.045, 0.052, and 0.046, respectively.

Analysis of Lacrimal Duct Morphology from Cone-Beam Computed Tomography Dacryocystography in a Japanese Population

Purpose

The dacryoendoscope is a practical instrument for the examination and the treatment of lacrimal duct obstruction. Nevertheless, as it is a rigid fiberscope, manipulation of the endoscope is somewhat affected by the patient’s lacrimal duct alignment and the skeletal structure of the face. The morphology and inclination of the lacrimal duct vary among individuals and ethnic groups. We aimed to evaluate the alignment of the lacrimal duct from the perspective of endoscopic maneuverability in a Japanese population.

Methods

This retrospective study analyzed the cone-beam computed tomography dacryocystography (CBCT-DCG) images of 102 patients diagnosed with unilateral primary acquired nasolacrimal duct obstruction (PANDO) at Ehime University Hospital from December 2015 to May 2021. The following parameters of the lacrimal duct on the contralateral side of unilateral PANDO were investigated: (1) angle formed by the superior orbital rim–internal common punctum–nasolacrimal duct opening, (2) angle formed by the lacrimal sac and the nasolacrimal duct, (3) length of the lacrimal sac, and (4) length of the nasolacrimal duct.

Results

Measurements of the above parameters were (1) 10.2° ± 7.8° (range, −11° to +27°), (2) −6.3° ± 14.1° (range, −43° to +40°), (3) 8.9 ± 2.3 mm (range, 4.3–17.1), and (4) 13.2 ± 2.7 mm (range, 5.7–20.7), respectively. The Shapiro–Wilk test demonstrated that the values of all parameters, except (3), followed a normal distribution (p = 0.55, 0.30, 0.0002, and 0.39, respectively). No significant difference was found between the female and male groups (p > 0.05).

Conclusion

This study reported anthropometric analysis data of the morphology of the lacrimal ducts using CBCT-DCG in a Japanese population. In our cohort, the line from the superior orbital rim through the internal common punctum to the nasolacrimal duct opening inclined anteriorly in 92% of the patients.

Acquired nasolacrimal duct obstruction: clinical and histological findings of 275 cases

Background

Acquired nasolacrimal duct obstruction is a blockage of the lacrimal outflow system usually caused by local nonspecific inflammation of the lacrimal sac and the nasolacrimal duct. However, cases exist where the primary nasolacrimal system obstruction is caused by malignancies.

Our aim was to investigate lacrimal sac pathologies in patients with acquired nasolacrimal duct obstruction and compare their clinical manifestations.

Methods

This retrospective clinical study included 275 patients with acquired nasolacrimal duct obstruction who underwent external dacryocystorhinostomy and lacrimal sac biopsy. Cases were classified into tumor or nonspecific pathology groups and subdivided according to the level of inflammation. Histological and clinical data were analyzed.

Results

Three tumors (1.1%) (an adenoid cystic carcinoma, an eccrine spiradenoma and small B cell lymphoma) were diagnosed. Chronic nongranulomatous inflammation was the most common histological finding, corresponding to 194 cases (70.5%). The other 81 (29.5%) were subacute, acute forms of nongranulomatous inflammation, tumors and fibrosis cases. Epiphora with continuous purulent discharge was the most common clinical sign reported by 144 (52.4%) patients, and two (0.7%) patients had a palpable mass near the medial canthal tendon, which was identified as an eccrine spiradenoma and small B cell lymphoma. There was no significant difference in the clinical symptoms, duration or case history between the nonspecific pathology and tumor groups (p = 0.292).

Conclusions

Chronic nongranulomatous inflammation of the lacrimal sac was the most common finding among acquired nasolacrimal duct obstruction cases. There were no associations between the histological findings and clinical presentation. The authors recommend a lacrimal sac biopsy only in cases when a tumor is clinically suspected.

Matrix Metalloproteinase-9 Point-of-Care Immunoassay after Dacryocystorhinostomy in Patients with Nasolacrimal Duct Obstruction

PURPOSE

To compare matrix metalloproteinase-9 (MMP-9) point-of-care immunoassay (InflammaDry) results before and after dacryocystorhinostomy (DCR) in patients with nasolacrimal duct (NLD) obstruction.

METHODS

Thirty-eight eyes of 38 patients who were diagnosed with unilateral NLD obstruction were treated with endoscopic DCR. Treatment response was monitored using InflammaDry test, tear meniscus height was measured by slit-lamp microscopy, and tear meniscus parameters (tear meniscus height, depth, and area) were measured by anterior segment optical coherence tomography at baseline and at 1 month after surgery.

RESULTS

In 38 patients, the positive percentage of MMP-9 in diseased eyes was 100% (38 eyes), much higher than that in healthy fellow eyes (13.2%, 5 of 38 eyes) at baseline (p<0.001, χ² test test). MMP-9 levels before and after surgery were significantly different (p<0.001), and MMP-9-positive eyes showed a significant improvement in MMP-9 grade after surgery (p< 0.0001; generalized McNemar test). Furthermore, other clinical parameters (tear meniscus area, tear meniscus height, and tear meniscus depth) showed a general improvement.

CONCLUSION

The concentration of MMP-9 increased in the tears of patients' eyes with NLD obstruction compared to the contralateral healthy eyes. These abnormal findings showed a significant improvement after DCR. The improvement of postoperative MMP-9 expression might be because of the improvement of tear retention.

Microbiological spectrum of microbial keratitis in patients presenting with nasolacrimal duct obstruction

PURPOSE

To study the type of bacteria and their antibiotic susceptibility pattern from corneal scrapings of patients with infectious keratitis presenting with concurrent nasolacrimal duct obstruction.

METHODS

A retrospective analysis was carried out of patients with microbial keratitis and co-existing nasolacrimal duct obstruction during a 5-year period (January 2012 to December 2016). Antibiotic susceptibility profile data was collected from the microbiology records.

RESULTS

The study included 56 (M:F = 33:23; OD:OS = 34:22) eyes. The mean age of patients was 60.2 ± 12.3 years. Microscopic examination of corneal scrapings showed 52% of gram-positive (n = 29/55) and 2% of multiple (>1; n = 1/55) bacteria. Streptococcus pneumoniae (32%, n = 18/56), coagulase-negative Staphylococcus (25%, n = 14/56), and Staphylococcus aureus (11%, n = 6/56) were the most common bacteria. Streptococcus pneumoniae was found to be susceptible to ciprofloxacin (72.2%), ofloxacin (94.4%), gatifloxacin (61.1%), and moxifloxacin (83.3%).

CONCLUSION

Corneal infection associated with nasolacrimal duct obstruction is commonly caused by gram-positive-bacteria. Irrigation of nasolacrimal duct should be mandatory test in microbial keratitis. The gram-positive bacteria isolated showed maximum susceptibility to vancomycin and cefazolin. Early treatment by surgery and appropriate medical management is recommended for its control.

Silicone Tubing after Endoscopic Dacryocystorhinostomy: Is it Necessary?

Background

Endoscopic dacryocystorhinostomy (EN-DCR) is increasing in popularity as a treatment of nasolacrimal obstructions because it has proven to be an effective and safe procedure. In this study the success of EN-DCR combined with or without bicanalicular silicone stents was evaluated in patients with nasolacrimal obstructions.

Methods

Forty-two consecutive EN-DCR procedures were performed in 36 patients during 2000–2004. The surgery was primary in 23 cases and revision in 19 cases. Bicanalicular silicone stents were inserted in 18 cases and in 24 cases stenting was avoided.

Results

The overall success rate after EN-DCR was 81%. The success rate of EN-DCR was 89% with silicone tubing and 75% without silicone tubing. The mean duration of postoperative follow-up was 4 months.

Conclusion

In our retrospective study no significant statistical differences were seen between the patients with stenting compared with patients without stenting. However, prospective, randomized studies are clearly needed to answer the question of whether the use of stents is advisable.

The role of interventional radiology in the treatment of epiphora

Epiphora is a relatively common ophthalmologic affection representing almost 5% of clinical consultations in ophthalmology and it consists in the complete or partial obstruction of nasolacrimal duct, leading to insufficient drainage of tears. The traditional treatment is represented by surgery namely, external dacryocystorhinostomy (DCR). Despite the high success rate DCR has many disadvantages and limitations since it requires general anesthesia, it may arise in a permanent facial scar and it is often affected by the reobstruction of the anastomotic tract by fibrotic scars and osteogenic activity. Fluoroscopically guided interventional procedures are a therapeutic alternative to surgery for lacrimal duct system obstructions that can consist either in balloon dacryocystoplasty or in nasolacrimal stent placement. In both cases, a pre-operative imaging characterization of the occlusion is needed for a correct treatment planning. In this review, we propose to highlight the role of interventional radiology in the treatment of epiphora and the role of computed tomography dacryocystography (CTD) in depiction and the pre-interventional planning.

Clinical significance of routine lacrimal sac biopsy during dacryocystorhinostomy: A comprehensive review of literature

The main purpose of this paper is to provide the information about the incidence and types of pathology of secondary acquired obstructions of the lacrimal excretory outflow system caused by primary lacrimal sac non-neoplastic and neoplastic lesions. After a thorough literature search, 17 case-control studies were found and selected, data were extracted and categorized, to evaluate specific lacrimal sac pathology mimicking inflammation. A total of 3865 histopathologically examined lacrimal sac wall biopsy specimens from 3662 patients, taken during dacryocystorhinostomy for clinically presumed primary chronic dacryocystitis, were analyzed. The most common reported histopathological finding was non-specific chronic inflammation with or without fibrosis (94.15% of cases). Lacrimal sac-specific pathologies were present in 226 (5.85%) cases. Unsuspected lacrimal sac-specific pathologies were present in 55/226 (24.34%) cases. Almost 45% of primary lacrimal sac malignant neoplasms were not suspected, preoperatively and intraoperatively. Tumor-like lesions of the lacrimal sac were the most common pathology found: (1) lacrimal stones-dacryoliths, (2) pyogenic granuloma, (3) granulation tissues, (4) reactive lymphoid hyperplasia, and (5) lacrimal sac-specific inflammation (Wegener's granulomatosis and sarcoidosis). Neoplastic pathology was found in 55/3865 (1.42%) lacrimal sac wall biopsy specimens; of those, malignant cases were 2.24 times more frequent than benign. Lymphoma was the most common preoperatively unsuspected or intraoperatively unexpected neoplastic pathology. This analysis of the relevant literature highlights the value of routine lacrimal sac biopsy during surgery for clinically presumed primary acquired nasolacrimal duct obstruction.

Lacrimal Duct Occlusion Is Associated with Infectious Keratitis

Background: To explore the prevalence of lacrimal duct obstruction in patients with infectious keratitis, and the necessity of lacrimal duct dredge in the treatment of human infectious keratitis. Methodology/Principle Findings: The design is prospective, non-control case series. Thirty-one eyes from twenty-eight continuous patients with infectious keratitis were included in this study. The presence/absence of lacrimal duct obstruction was determined by the lacrimal duct irrigation test. The diagnosis of infectious keratitis was made based on clinical manifestations, cornea scraping microscopic examination and bacterial/fungus culture. Diagnosis of viral keratitis was set up based on the recurrent history, deep neovascularization and typical outlook of the cornea scar. The treatment of keratitis included drugs, eye drops or surgery, while treatment of chronic dacryocystitis was lacrimal duct dredging with supporting tube implantation surgery. In the thirty-one eyes with infectious keratitis, fifteen suffered from fungal keratitis (48%), two bacterial keratitis (6%), and fourteen viral keratitis (45%). Eleven eyes (35%) from ten patients with infectious keratitis also suffered from lacrimal duct obstruction. In those cases, six eyes also suffered from lower canalicular obstruction, three nasolacrimal duct obstruction and chronic dacryocystitis, one a combination of upper and lower canalicular obstruction, one upper canalicular obstruction. After local and systemic applications of anti-bacterial, anti-viral, anti-fungal and anti-inflammatory drugs, twenty-eight eyes (90%) recovered within three weeks, while the ulceration of three patients required the lacrimal duct dredging and supporting tube implantation surgery for the healing. Conclusions: Herein, we first report that the prevalence of infectious keratitis is closely correlated to the occurrence of lacrimal duct obstruction. When both confirmed, simultaneous treatment of keratitis and lacrimal duct obstruction promptly is required. Further evaluation of mechanism, prevention and control of the diseases are warranted.

Comparison of transcanalicular diode laser dacryocystorhinostomy and external dacryocystorhinostomy in patients with primary acquired nasolacrimal duct obstruction

BACKGROUND AND OBJECTIVE

To compare the success, complication, and patient discomfort rates of transcanalicular diode laser dacryocystorhinostomy (TCDL-DCR) and external dacryocystorhinostomy (EX-DCR) surgeries performed in patients with primary acquired nasolacrimal duct obstruction.

MATERIALS AND METHODS

Eighty consecutive patients were included in the study, and groups were assigned according to DCR technique. Thirty-four (42.5%) patients received TCDL-DCR (Group A) and 46 (57.5%) patients (Group B) received EX-DCR with temporary silicone stent intubation. The success of surgery was determined by the relief of epiphora, patient satisfaction, endoscopic evaluation of ostium patency, and lacrimal system syringing. Pearson Chi-Square test, Fisher's Exact test, and Student's t-test were used for statistical analyses.

RESULTS

Group A included 22 females and 12 males with a mean age of 49.1 ± 15.1 years, Group B included 35 females and 11 males with a mean age of 50.8 ± 11.7 years. There was no difference between groups in terms of age and gender (P = 0.905 and P = 0.167, respectively). The duration of the operation was 22.2 ± 4.8 minutes for Group A, while it was 56.3 ± 15.7 minutes for group B (P = 0.0001). In two patients in Group A, injury in the medial turbinate was recorded, and in Group B, 14 patients experienced mild to severe perioperative bleeding. The perioperative complication rate was significantly different between the groups (P = 0.004). Success in relieving symptoms was 79.4% for Group A and 89.1% for Group B. The difference in the success rates was not statistically significant (P = 0.229).

CONCLUSIONS

Although EX-DCR success rate was higher than that achieved with TCDL-DCR, the latter, with its shorter duration of surgery, lower perioperative complication rate, and a similar success rate, may be a good and acceptable surgical alternative in treatment of primary acquired nasolacrimal duct obstruction.

Lacrimal system endoscopy assisted endonasal dacryocystorhinostomy

OBJECTIVE

To assess the potential benefit of intra-operative lacrimal system endoscopy during endonasal dacryocystorhinostomy.

METHODS

Eight patients (10 cases) underwent lacrimal system endoscopy assisted endonasal dacryocystorhinostomy for nasolacrimal duct obstruction between May 2010 and July 2012 at the New York Presbyterian Hospital/Weill Cornell Medical College. All patients were subsequently followed post-operatively for at least 6 months. Primary outcome measures included post-operative epiphora and infection.

RESULTS

Lacrimal system endoscopy assisted endonasal dacryocystorhinostomy was successful in identifying the level of nasolacrimal duct obstruction in all 10 cases. Endoscopy revealed obstruction at the valve of Hasner in 2 cases, while the remaining cases involved obstruction at more proximal locations within the nasolacrimal duct. The location of the rhinostomy created during dacryocystorhinostomy was tailored to the specific level of obstruction. No intra-operative complications were encountered. The majority of patients (6 of 8) experienced complete resolution of epiphora within 1 month of surgery, with all patients achieving resolution by 6 months. None of the patients in the study exhibited any signs of post-operative dacryocystitis.

CONCLUSION

The evaluation and management of nasolacrimal duct obstruction may be greatly enhanced through the use of intra-operative lacrimal system endoscopy by specifically localizing and identifying the underlying cause of obstruction, while maintaining the excellent success rate of endonasal dacryocystorhinostomy.

Results of combined multispecialty endoscopic dacryocystorhinostomy

OBJECTIVE

To characterize the pre- and post-operative findings in patients undergoing endoscopic dacryocystorhinostomy (eDCR) performed jointly by ophthalmologists and otolaryngologists.

METHODS

Retrospective case series consisting of all the patients who underwent eDCR for nasolacrimal duct obstruction at New York Presbyterian Hospital/Weill Cornell Medical College between the 2009-2012 academic years. Patients were followed post-operatively for at least six months. The primary endpoint assessed in this study was symptom recurrence (epiphora).

RESULTS

A total of 20 patients (25 total cases) underwent eDCR within the study interval. Of the 25 cases, 7 (28.0%) represented reoperations due to recurrent symptoms. All 20 patients in the study exhibited sinus pathology, as determined during a pre-operative otolaryngology assessment. As a result, 16 of these patients (80.0%) underwent concurrent sinonasal surgery at the time of eDCR. The success rate in cases without prior DCR was 83.3% (15/18). Only 57.1% of revision cases (4/7) reported resolution of epiphora following surgery.

CONCLUSION

While a joint approach to eDCR did not appear to significantly improve efficacy, it offered the advantage of having an otolaryngologist assess and treat concurrent sinonasal pathology, which was seen in every patient in our series. Given our findings, as well as the technical difficulty often associated with the procedure, there may be great utility in performing eDCR in conjunction with an otolaryngologist.

Management and outcomes of patients with epiphora referred to a specialist ophthalmic plastic unit

BACKGROUND

To describe the aetiology and management of the symptom epiphora presenting to a specialist ophthalmic service.

DESIGN

A retrospective case series and patient postal questionnaire of all new referrals seen in a specialist unit with primary symptoms of epiphora between January 2007 and December 2008. The study was begun in 2010 to allow a 2-year follow-up for this cohort.

PARTICIPANTS

Two hundred thirty-seven patients were identified, of which 192 met the inclusion criteria. Fifty-seven were male, 135 were female, with a mean age of 60.7 (range 0-95) years.

METHODS

Patients were identified using a key word search of clinic letters and a search of primary care coding.

MAIN OUTCOME MEASURES

Duration of symptoms, referral source, aetiology and subjective improvement of symptoms post treatment.

RESULTS

At consultation, patients had experienced epiphora for a mean of 41.1 (range 0.066-360) months. A diagnosis of partial or complete nasolacrimal duct obstruction (31.8%), dry eye with secondary reflex tearing (29.2%), eyelid malposition (10.4%) and multi-factorial epiphora (28.7%) was made after follow-up and treatment. A postal questionnaire follow-up showed that 25% of patients no longer had any epiphora, with 67% reporting an improvement in their symptoms. Final follow-up was 30-54 months.

CONCLUSIONS

This study highlights the protean aetiology of the symptom and sign, epiphora. Sparse data exist on the audited success in managing this common symptom and sign. This study helps introduce an example of a benchmark for evaluating the effectiveness of epiphora. The majority of patients were referred, usually by ophthalmologists for lacrimal surgery.

A comparison of external and endonasal dacryocystorhinostomy in regard to patient satisfaction and cost

BACKGROUND

Definitive treatment of nasolacrimal duct obstruction is with external or endonasal dacryocystorhinostomy (DCR). Recent trials suggest surgical equivalency between techniques. We sought to compare alternative outcomes of DCR techniques in terms of quality of life and cost.

METHODS

This study was a multicentre prospective nonrandomized case series comparing adult patients treated with external or endonasal DCR. Groups were allocated according to DCR technique. Participation did not affect treatment choice. The Glasgow Benefit Inventory (GBI) was utilized to compare postoperative quality of life, and an activity-based costing (ABC) method used to estimate costs of the two techniques. Surgical data were also collected. A minimum of 3 months follow-up was observed.

RESULTS

Seventy-seven patients were included--37 external and 40 endonasal. Both techniques resulted in positive health status change, with mean GBI scores of +16.1 for external DCR and +24.1 for endonasal (p = 0.18). Using an ABC method, the operative costs of external DCR were less than endonasal at $715.79 AUD and $932.52 AUD respectively.

CONCLUSIONS

This trial suggests that external and endonasal DCR produce comparable outcomes in terms of postoperative quality of life, with external DCR resulting in lower operative costs.

MR dacryocystography in the evaluation of patients with obstructive epiphora treated by means of interventional radiologic procedures

BACKGROUND AND PURPOSE

Most imaging techniques used for the evaluation of obstructive epiphora, such as DS DCG, rely on undesired ionizing radiation. We evaluated the efficacy of topical contrast-enhanced MR DCG in comparison with DS DCG in patients with obstructive epiphora who underwent balloon DCG or stent placement.

MATERIALS AND METHODS

Thirty-six LDSs of 21 patients treated with balloon DCG (n = 11) or stent placement (n = 11) were examined with MR DCG and DS DCG. Contralateral LDSs (n = 14) were also evaluated in patients with unilateral disease. A sterile 0.9% NaCl solution containing 1:100 diluted gadolinium chelate was instilled into conjunctival sacs. The 3D FSPGR sequence was used with a 1.5T scanner. MR and DS DCG findings were scored and compared according to morphology of the lacrimal sac, junction, and NLD and the presence of contrast media in the nasal cavity.

RESULTS

Comparison of MR DCG and DS DCG findings showed no significant statistical differences in reference to anatomic locations according to the McNemar test (P > .05). Good or very good agreement (κ value > 0.61) was observed according to the κ statistics.

CONCLUSIONS

Topical contrast-enhanced MR DCG is an effective and reliable noninvasive method for evaluation of the LDS in patients treated with IR procedures. This method avoids both cannulation and ionizing radiation and can, therefore, be repeated as often as is necessary in these complex patients.

A 7-year prospective study of routine histopathological evaluation of the lacrimal sac wall incisional biopsy specimens obtained during external dacryocystorhinostomy in adults and a review of the literature

The most common lacrimal sac pathology is chronic inflammation with or without occlusive fibrosis. However, a substantial number of lacrimal sac-specific pathologies were reported throughout the literature which may mimic chronic inflammation and be misdiagnosed. From a tertiary ophthalmic care centre in Serbia, in a single ophthalmic pathology laboratory, during a 7-year period (January 2004 to October 2010), a 599 consecutive lacrimal sac wall biopsy samples routinely obtained during external dacryocystorhinostomy in adult patients with clinically presumed primary acquired lacrimal drainage system obstruction were analysed. Although non-specific lacrimal sac pathology was present in the vast majority of cases (578 biopsy specimens; 96.49%), this report also reveals a relatively substantial number (21 biopsy specimens; 3.51%) of clinically non-suspected or intraoperatively unexpected primary lacrimal sac-specific pathology--among them, six lesions with malignant biological behaviour were identified: one microinvasive squamous cell carcinoma and five malignant lymhoproliferative lesions. Usefulness of routine lacrimal sac wall biopsy during surgery for primary acquired lacrimal drainage system obstruction is undoubtful and commensurate with the constant need for better understanding of the pathological processes that involve lacrimal drainage system.

Transcanalicular diode laser-assisted dacryocystorhinostomy

Objective:

We present a prospective, non-comparative case series study of 126 consecutive diode laser-assisted transcanalicular dacryocystorhinostomy (TCL-DCR) procedures on 122 patients. We analyzed success rate, procedure time and amount of laser energy needed for a 5 mm osteotomy.

Materials and Methods:

One hundred and twenty-two patients with nasolacrimal duct obstruction were included in the study. The procedure was performed under general anesthesia, and the nasal mucosa was anesthetized. An endoscope was used for examination of the lacrimal pathways. The site of osteotomy was determined with transillumination of the lateral nasal wall. We achieved osteotomy by applying laser energy via an optic fiber. We used a 980 nm diode laser with power of 10 Watts. We inserted a bicanalicular silicone stent as the last step. Success of procedure was absence of epiphora (subjective), or patency of the lacrimal drainage system on irrigation (objective).

Results:

We performed 126 successive endoscopic laser (EL-DCR) with bicanalicular intubation in 122 patients. The average procedure time was 12 min, and on average 245 Joules of laser energy was needed. The silicone stents were removed three to eight months after surgery. We observed absence of epiphora and a patent nasolacrimal duct on irrigation in 105 out of 126 treated eyes. Eighteen patients had epiphora despite a patent nasolacrimal duct on irrigation. This yields a success rate of 83.3%, with an average follow-up period of 12 months.

Conclusions:

The 980 nm EL-DCR with bicanalicular intubation is a new contribution to the field of lacrimal surgery. It is a minimally invasive quick procedure yielding a high success rate.

A simple and evolutional approach proven to recanalise the nasolacrimal duct obstruction

Aim:

To evaluate a new approach of recanalisation of nasolacrimal duct obstruction (RC-NLDO) in the treatment of the nasolacrimal duct obstruction (NLDO) and chronic dacryocystitis.

Methods:

583 patients with 641 eyes suffering from NLDO and chronic dacryocystitis were enrolled in this study. The RC-NLDO was performed in 506 eyes, with 135 eyes undergoing external dacryocystorhinostomy (EX-DCR) as controls. Patient follow-up for 54 months was evaluated by symptoms, dye disappearance test, lacrimal irrigation and digital subtraction dacryocystogram. The RC-NLDO was also performed in 12 rhesus monkeys for histopathological examination.

Results:

The clinical success rates were 93.1% in 506 cases of RC-NLDO and 91.11% in 135 cases of EX-DCR. The success rates for second surgery were achieved in 85.19% on RC-NLDO and 40.0% on EX-DCR. No major intra- or postoperative complications were observed in the RC-NLDO group. The mean operative duration was 12.5 min for RC-NLDO and 40.3 min for EX-DCR (p<0.001). A pathological study in rhesus monkeys demonstrated that the RC-NLDO wounded epithelium in nasolacrimal duct healed completely within 1 month without granulation tissue formation.

Conclusion:

The findings demonstrate that the RC-NLDO is a simple and effective approach proven to recanalise the obstructed nasolacrimal duct with a comparable success rate to EX-DCR.

Comparison of surgical outcomes of endonasal dacryocystorhinostomy with or without mucosal flaps

OBJECTIVE

The goals of this study were to evaluate the long-term results of endoscopic endonasal dacryocystorhinostomy (DCR) with or without a posterior mucosal flap and to compare the surgical success rates of that procedure in patients with a nasolacrimal duct obstruction.

PATIENTS AND METHODS

We retrospectively investigated the results of 78 endoscopic endonasal DCRs performed at the Baskent University, Department of Otolaryngology between December 2000 and March 2007 on 74 patients with a lacrimal obstruction. The patients were divided into two groups. During surgery, the posterior mucosal flap was preserved in 27 patients (group A) and removed in 47 patients (group B). All patients underwent intubation with a silicone tube at the conclusion of surgery. The silicone tube was removed within 6 months after surgery. The mean follow-up period was 36 months (range, 2-78 months). The results obtained were then compared.

RESULTS

Granulation tissue and synechia developed between the lateral nasal wall and the middle turbinate in one patient in group A (revision surgery was not required). In group B, granulation tissue at the rhinostomy opening was found in seven patients, and in four of those subjects, the granulation tissue obstructed the neo-ostium. These four patients underwent a second operation. In group B, synechia was noted between the middle turbinate and the lateral nasal wall in two of 47 patients. In group A, the procedure was successful for all patients except one in whom granulation tissue developed, and in group B, the surgical success rate was 88.3%.

CONCLUSION

In endoscopic endonasal DCR, the closure of bare bone with a posteriorly based nasal mucosal flap that creates an anastomosis between the lacrimal sac mucosa and the nasal mucosa decreases the formation of granulation tissue. But, there is no significant difference of success rate between two groups.

Interventional radiology in the lacrimal drainage system

This article presents a review of the interventional radiological procedures in the lacrimal drainage system. Balloon dacryocystoplasty and nasolacrimal polyurethane stent placement are the main fluoroscopically guided interventions for the treatment of epiphora by recanalizing the obstructed LDS. These procedures can also be used for dacryolith removal and lacrimal sac abscess treatment.